In the first year that two Florida laws aimed at curbing opioid prescriptions were in effect, the state's top opioid prescribers wrote significantly fewer prescriptions of this type of pain medication, a new analysis led by researchers at the Johns Hopkins Bloomberg School of Public Health finds.

At the same time, the law did not effect the extreme concentration of opioid prescribing among a small group of providers - approximately four percent of prescribers accounted for 40 percent of the prescriptions for opioid painkillers that made up two-thirds of all such pills prescribed in Florida. Primary care physicians made up more than half of the top prescribers. These findings suggests both the potential impact of policies at curtailing prescriptions among high-volume prescribers and the limits of the new policies, since many physicians still prescribed at high rates.

The new analysis followed patients and prescribers from July 2010 through November 2012; the two policies were implemented in late 2011. The first policy created the state's Prescription Drug Monitoring Program (PDMP), a database that tracks individual prescriptions, including patient names, dates and amounts prescribed, so physicians can be on the lookout for people with multiple prescriptions from multiple doctors, something associated with addiction and illicit use. The second law addressed so-called "pill mills," loosely regulated pain clinics that often see disproportionately high levels of opioid prescriptions. Florida's "pill mill" measure requires clinics to register with the state and to be owned by a physician.

During the one-year period after the law went into effect, the researchers estimate that opioid prescriptions by Florida's top opioid prescribers fell 6.2 percent and the total volume prescribed by this group dropped 13.5 percent (compared to a scenario in which the laws were not implemented). In this group, the number of patients also dropped, by 5.1 percent. (The top four percent included 1,526 providers out of a total of 38,465 in the state.) Among the remaining 96 percent of prescribers, prescriptions slipped a mere 0.7 percent.

The findings will appear online June 2 in the journal Drug and Alcohol Dependence.

Opioid misuse and abuse has reached epidemic proportions in the U.S., with an average of 44 people dying from opioids each day. To address the epidemic, the Centers for Disease Control and Prevention recently issued new guidelines for prescribers initiating opioids for non-cancer pain in primary care. The guidelines recommend that prescribers use opioids only after other treatments have failed and that they use them at lower doses and shorter durations than in the past. In addition, every state in the country except for Missouri now has a Prescription Drug Monitoring Program in place.

"Our findings indicate how state policies such as PDMPs may reduce opioid use among the highest prescribers," says Hsien-Yen Chang, PhD, an assistant scientist in the Bloomberg School's Department of Health Policy and Management and the study's lead author. "But our report also shows that programs like PDMPs must be complemented by many other measures to combat the epidemic of addiction and non-medical opioid use."

For the analysis, the researchers compared prescription data from IMS Health's LRx for both Florida and Georgia, which at the time did not have either a prescription database or a 'pill mill' policy in place. The research team compared opioid prescriptions between July 2010 and June 2011 - before the laws went into effect - with those made between October 2011 and November 2012. (The three-month interval, July 2011 through September 2011, allowed for Florida's two new laws to take effect.) The researchers identified the top, or 'high risk,' providers who prescribed the most opioid painkillers for four consecutive quarters. (By 'high risk' prescribers, the authors mean those most likely to prescribe opioids. They note that it is a quantitative rather than a qualitative descriptor.)

Chang notes that the researchers did not have information about patients' diagnoses, and could therefore not assess the degree to which the prescriptions were clinically appropriate, either before or after the policies went into effect.

"When we looked at the prescription numbers in the year before the two laws went into effect, we were very surprised at how concentrated the prescriptions were among a subset of prescribers," says the study's senior author G. Caleb Alexander, MD, MS, an associate professor in the Bloomberg School's Department of Epidemiology. "At the same time, these aren't the only prescribers that we should worry about. There is an unmistakable correlation between the volume of opioids on the market and injuries and deaths from these drugs, and health care providers have a shared responsibility for the extent that these products are prescribed."

The authors note that it is difficult to fully separate the impact of the PDMP and the pill-mill law. But they argue that doctors should get in the habit of checking the database before they write a prescription.

"At some point, checking the prescription database before prescribing an opioid should be just as routine as doing a kidney test before starting a new blood pressure treatment," Dr. Alexander says. "I think we'll get to that point; we'll see prescription databases used like these other tools and have an even greater impact."

This work was funded by the Robert Wood Johnson Foundation (RWJF) Public Health Law Research Program and the Centers for Disease Control and Prevention (CDC) under Cooperative Agreement U01CE002499. The RWJF had no role in the design and conduct of the study, analysis, or interpretation of the data; and preparation or final approval of the manuscript prior to publication. The CDC provided input regarding the interpretation of the study but had no role in the final decision to submit the manuscript for publication. Despite this, the opinions and conclusions expressed are solely of the author(s) and should not be construed as representing the opinions of CDC or any agency of the Federal Government.

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